Justin A. Shuffer, D.D.S., Pediatric Dentistry - Pediatric ...



1647824-714376 00 -634365588010Welcome to our practice! We pledge to render the finest pediatric dental care possible for your family.Thank you in advance for the valuable information requested below. Today’s date________________Child (Patient) InformationChild’s Name _______________________________ Nickname ________________________ Gender M FAge ______ Date of Birth ______________ Child’s Pediatrician _____________________________Emergency Contact: ________________________ Pediatrician Address _____________________________Phone number: _____________________ _____________________________Whom may we thank for referring you to our office? _________________________________________Is your child covered by a dental plan or insurance? Yes No If yes, which insurance? _______________Is this your child’s first dental visit? Yes NoIf no, name of previous dentist ___________________________ Approximate date of last visit _____________Reason for this dental visit ____________________________________________________________________Is your child currently in pain or requiring treatment Yes NoDo you know any other children that are patients in this office? Yes NoIf yes, please list their names __________________________________________________________________Has your child had any bad dental experiences? Yes NoIf yes, please explain _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What are your child’s favorite things? ____________________________________________________________Was your child bottle fed?YesNoIf yes, until what age? ____________Was your child breast fed?YesNoIf yes, until what age? ____________Does your child drink juice?YesNoIf yes, how many ounces/day ______Does your child drink soda?YesNoIf yes, how many cans/week _______Does your child brush and floss alone?YesNoDoes your child drink tap water?YesNoDoes your child drink milk or juice to bed?YesNoIs there a water filtration system in the home?YesNoDoes your child have any of the following mouth habits?Thumb suckingFinger suckingLip sucking Tooth grindingMouth breatherTongue thrustingForeign objects in mouthSelf injuryHas your child had any injuries to his teeth, mouth, head, or jaw? _______________________________________Does your child receive fluoride in any of the following forms?VitaminsWater supplyTablets/dropsToothpasteRinse/gelPrescription dosage _____ mg/dayPlease circle any items your child routinely eats/drinks between meals:JuiceGummi vitaminsGummi Fruit snacksChocolate milkSodaCrackers/chipsSports drinksSoy Milk My child is foster/adopted and has lived with me for _____ years N/A00Welcome to our practice! We pledge to render the finest pediatric dental care possible for your family.Thank you in advance for the valuable information requested below. Today’s date________________Child (Patient) InformationChild’s Name _______________________________ Nickname ________________________ Gender M FAge ______ Date of Birth ______________ Child’s Pediatrician _____________________________Emergency Contact: ________________________ Pediatrician Address _____________________________Phone number: _____________________ _____________________________Whom may we thank for referring you to our office? _________________________________________Is your child covered by a dental plan or insurance? Yes No If yes, which insurance? _______________Is this your child’s first dental visit? Yes NoIf no, name of previous dentist ___________________________ Approximate date of last visit _____________Reason for this dental visit ____________________________________________________________________Is your child currently in pain or requiring treatment Yes NoDo you know any other children that are patients in this office? Yes NoIf yes, please list their names __________________________________________________________________Has your child had any bad dental experiences? Yes NoIf yes, please explain _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What are your child’s favorite things? ____________________________________________________________Was your child bottle fed?YesNoIf yes, until what age? ____________Was your child breast fed?YesNoIf yes, until what age? ____________Does your child drink juice?YesNoIf yes, how many ounces/day ______Does your child drink soda?YesNoIf yes, how many cans/week _______Does your child brush and floss alone?YesNoDoes your child drink tap water?YesNoDoes your child drink milk or juice to bed?YesNoIs there a water filtration system in the home?YesNoDoes your child have any of the following mouth habits?Thumb suckingFinger suckingLip sucking Tooth grindingMouth breatherTongue thrustingForeign objects in mouthSelf injuryHas your child had any injuries to his teeth, mouth, head, or jaw? _______________________________________Does your child receive fluoride in any of the following forms?VitaminsWater supplyTablets/dropsToothpasteRinse/gelPrescription dosage _____ mg/dayPlease circle any items your child routinely eats/drinks between meals:JuiceGummi vitaminsGummi Fruit snacksChocolate milkSodaCrackers/chipsSports drinksSoy Milk My child is foster/adopted and has lived with me for _____ years N/A-7486658575040Phone: (909) 599-0283 | 00Phone: (909) 599-0283 | -923925-123761500-485775161925HealthIs your child in good health?YesNoAre your child’s immunizations up to date?YesNoDoes your child have any conditions requiring treatment currently?YesNoIf yes, please explain __________________________________ __________________________________Does your child currently take any medications?YesNoIf yes, please list ______________________________________Does your child have any allergies or reactions to any medications?YesNoIf yes, please list ______________________________________Has your child ever been hospitalized or had surgery?YesNoIf yes, please explain ___________________________________Has your child had any history of?Heart Trouble- - - - - - - - - - - - - - - - - - - - - - - -YesNoDiabetes - - - - - - - - - - - - - - - - - - YesNoHeart Murmur- - - - - - - - - - - - - - - - - - - - - - - -YesNoFainting/Seizures/Epilepsy- - - - - - YesNoRheumatic Fever- - - - - - - - - - - - - - - - - - - - - - - -YesNoGrowth/Develop Problems - - - - - - YesNoAcid Reflux - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoHearing/Speech Problems - - - - - - YesNoAnemia- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Yes NoHIV/AIDS - - - - - - - - - - - - - -- - - YesNoADD/ADHD - - - - - - - - - - - - - - - - - - - - - - - - - - Yes NoHemophilia - - - - - - - - - - - - - - - YesNoAsthma- - - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoHepatitis/Liver Disease - - - - - - -YesNoAutism- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoKidney Disease- - - - - - - - - - - - YesNoBirth Defects - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoLeukemia - - - - - - - - - - - - - - - - YesNoBlood Disorders- - - - - - - - - - - - - - - - - - - - - - -YesNoMental/Emotional Issues- - - - - YesNoBlood Transfusions - - - -- - - - - - - - - - - - - - - - - -YesNoPremature Birth- - - - - - - - - - - - YesNoBone or joint problems - - - - - - - - - - - - - - - - - - - YesNoSpina Bifida - - - - - - - - - - - - - - -YesNoBrain Injury - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoSyndrome - - - - - - - - - - - - - - - - YesNoCancer or Growths - - - - - - - - - - - - - - - - - - - - - - YesNoTuberculosis - - - - - - - - - - - - - - - YesNoCerebral Palsy - - - - - - - - - - - - - - - - - - - - - - - - - YesNoEye Problems - - - - - - - - - - - - - - YesNoChild Abuse - - - - - - - - - - - - - - - - - - - - - - - - - - -YesNoOther_____________________________Chronic ear infections - - - - - - - - - - - - - - - - - - - -YesNoSyndrome ___________________________Cleft Lip/Palate- - - - - - - - - - - - - - - - - - - - - - - - YesNoParent/Guardian InformationFather’s Full NameMother’s Full NameDriver’s LicenseDriver’s LicenseSocial Security NumberSocial Security NumberBirthdateBirthdate AddressAddressCityCityStateZip CodeStateZip CodeHome PhoneHome PhoneBusiness PhoneBusiness PhoneCell PhoneCell PhoneEmailEmailEmployerEmployerOccupationOccupation Child lives with:Both ParentsMotherFatherOtherI give this office my authorization to contact me on the above cell phones and send text messages regarding dental appointments, account balances, insurance information, patient care, etc. YES NO If No, please provide an alternative way for us to contact you ________________________________The undersigned hereby authorizes the office of Dr.Justin A. Shuffer, DDS, Inc. following explanation of procedures involved, to perform any and all forms of treatment, medication, and therapy, that may be indicated in connection with the care of the above named child. The undersigned understands that previous to treatment, full explanation of procedure(s) involved will be given by Dr.Justin A. Shuffer and/or associates and/or staff.Signature _____________________________ Relationship to patient ___________________ Date ______________00HealthIs your child in good health?YesNoAre your child’s immunizations up to date?YesNoDoes your child have any conditions requiring treatment currently?YesNoIf yes, please explain __________________________________ __________________________________Does your child currently take any medications?YesNoIf yes, please list ______________________________________Does your child have any allergies or reactions to any medications?YesNoIf yes, please list ______________________________________Has your child ever been hospitalized or had surgery?YesNoIf yes, please explain ___________________________________Has your child had any history of?Heart Trouble- - - - - - - - - - - - - - - - - - - - - - - -YesNoDiabetes - - - - - - - - - - - - - - - - - - YesNoHeart Murmur- - - - - - - - - - - - - - - - - - - - - - - -YesNoFainting/Seizures/Epilepsy- - - - - - YesNoRheumatic Fever- - - - - - - - - - - - - - - - - - - - - - - -YesNoGrowth/Develop Problems - - - - - - YesNoAcid Reflux - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoHearing/Speech Problems - - - - - - YesNoAnemia- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Yes NoHIV/AIDS - - - - - - - - - - - - - -- - - YesNoADD/ADHD - - - - - - - - - - - - - - - - - - - - - - - - - - Yes NoHemophilia - - - - - - - - - - - - - - - YesNoAsthma- - - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoHepatitis/Liver Disease - - - - - - -YesNoAutism- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoKidney Disease- - - - - - - - - - - - YesNoBirth Defects - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoLeukemia - - - - - - - - - - - - - - - - YesNoBlood Disorders- - - - - - - - - - - - - - - - - - - - - - -YesNoMental/Emotional Issues- - - - - YesNoBlood Transfusions - - - -- - - - - - - - - - - - - - - - - -YesNoPremature Birth- - - - - - - - - - - - YesNoBone or joint problems - - - - - - - - - - - - - - - - - - - YesNoSpina Bifida - - - - - - - - - - - - - - -YesNoBrain Injury - - - - - - - - - - - - - - - - - - - - - - - - - - - YesNoSyndrome - - - - - - - - - - - - - - - - YesNoCancer or Growths - - - - - - - - - - - - - - - - - - - - - - YesNoTuberculosis - - - - - - - - - - - - - - - YesNoCerebral Palsy - - - - - - - - - - - - - - - - - - - - - - - - - YesNoEye Problems - - - - - - - - - - - - - - YesNoChild Abuse - - - - - - - - - - - - - - - - - - - - - - - - - - -YesNoOther_____________________________Chronic ear infections - - - - - - - - - - - - - - - - - - - -YesNoSyndrome ___________________________Cleft Lip/Palate- - - - - - - - - - - - - - - - - - - - - - - - YesNoParent/Guardian InformationFather’s Full NameMother’s Full NameDriver’s LicenseDriver’s LicenseSocial Security NumberSocial Security NumberBirthdateBirthdate AddressAddressCityCityStateZip CodeStateZip CodeHome PhoneHome PhoneBusiness PhoneBusiness PhoneCell PhoneCell PhoneEmailEmailEmployerEmployerOccupationOccupation Child lives with:Both ParentsMotherFatherOtherI give this office my authorization to contact me on the above cell phones and send text messages regarding dental appointments, account balances, insurance information, patient care, etc. YES NO If No, please provide an alternative way for us to contact you ________________________________The undersigned hereby authorizes the office of Dr.Justin A. Shuffer, DDS, Inc. following explanation of procedures involved, to perform any and all forms of treatment, medication, and therapy, that may be indicated in connection with the care of the above named child. The undersigned understands that previous to treatment, full explanation of procedure(s) involved will be given by Dr.Justin A. Shuffer and/or associates and/or staff.Signature _____________________________ Relationship to patient ___________________ Date ______________1504951-66675000-923925-91122500-7048507933055Phone: (909) 599-0283 | 00Phone: (909) 599-0283 | 1247776-714375Justin A. Shuffer, D.D.S.Specialist in Pediatric DentistryInfants – Children – Special Needs (Enter Company Name00Justin A. Shuffer, D.D.S.Specialist in Pediatric DentistryInfants – Children – Special Needs (Enter Company Name-914400-91186000-590550361950For Patients Covered by InsurancePrimary CarrierSecondary CarrierSubscriber NameSubscriber NameSubscriber IDSubscriber IDInsurance Company, Address, and PhoneInsurance Company, Address, and PhoneEmployer Name, Address, and PhoneEmployer Name, Address, and PhoneGroup/Policy NumberGroup/Policy NumberHow long have you had this coverage?How long have you had this coverage?In order to comply with most insurance companies, we ask that you sign below so that we may keep your signature on file. I have reviewed the following treatment plan. I authorize the release of any information relating to this claim. I authorize payment of the dental benefits directly to the dentist._____________________________________________________________________Signature of patient or parent (if minor)Signature of patient or parent (if minor)Assignment of Benefits (If insured)I hereby assign all dental benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s) to issue payment check(s) directly to Justin A. Shuffer, DDS, Inc – Pediatric Dentistry for dental services rendered to myself and/or my dependent(s) regardless of my insurance benefits, if any. The office of Justin A. Shuffer, DDS, Inc will provide an estimate of insurance coverage upon request. I understand that the office of Justin A. Shuffer, DDS, Inc is not responsible for inaccurate estimates. Payment(s) of a dental claim is not guaranteed by any insurance and is based on eligibility and policy coverage at the time a claim is submitted. I understand that I am responsible for any amount not covered by insurance and I agree to pay any balance amount, in a timely manner. Initial: ________Office PolicyYour appointment time is important to you, your doctor, and to others who are in need of pediatric specialty dental care. We charge for missed appointments and our requested cancellation policy is a 24 hour notice for all types of visits. A $35 Fee will be assessed per child for any missed or cancelled appointment without appropriate notice. Your cancellation must be made during regular office hours. You will be personally responsible for this charge. This charge will not be billed to, nor paid for, by your insurance company. As always, emergencies and unforeseen circumstances are taken into consideration. Initial: __________Informed Consent Information Name: ____________________________Required Treatment: I understand that my child requires the following treatment:□ Radiographs/X-rays □ Local Anesthetic Injection□ Filling/Restoration □ Prophylaxis □ Extraction □ Sealants □ Pulp Treatment □ Crowns □ Space Maintainer□ Mouth Prop □ FluorideRadiographs/X-rays – A radiographic image is formed by a controlled burst of X-ray radiation which penetrates oral structures at different levels allowing pictures of the teeth, bones, and surrounding soft tissues to screen for and help identify problems with the teeth, mouth, and jaw. X-ray pictures can show cavities, cancerous or benign masses, and hidden dental structures (such as wisdom teeth).__________Initial00For Patients Covered by InsurancePrimary CarrierSecondary CarrierSubscriber NameSubscriber NameSubscriber IDSubscriber IDInsurance Company, Address, and PhoneInsurance Company, Address, and PhoneEmployer Name, Address, and PhoneEmployer Name, Address, and PhoneGroup/Policy NumberGroup/Policy NumberHow long have you had this coverage?How long have you had this coverage?In order to comply with most insurance companies, we ask that you sign below so that we may keep your signature on file. I have reviewed the following treatment plan. I authorize the release of any information relating to this claim. I authorize payment of the dental benefits directly to the dentist._____________________________________________________________________Signature of patient or parent (if minor)Signature of patient or parent (if minor)Assignment of Benefits (If insured)I hereby assign all dental benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s) to issue payment check(s) directly to Justin A. Shuffer, DDS, Inc – Pediatric Dentistry for dental services rendered to myself and/or my dependent(s) regardless of my insurance benefits, if any. The office of Justin A. Shuffer, DDS, Inc will provide an estimate of insurance coverage upon request. I understand that the office of Justin A. Shuffer, DDS, Inc is not responsible for inaccurate estimates. Payment(s) of a dental claim is not guaranteed by any insurance and is based on eligibility and policy coverage at the time a claim is submitted. I understand that I am responsible for any amount not covered by insurance and I agree to pay any balance amount, in a timely manner. Initial: ________Office PolicyYour appointment time is important to you, your doctor, and to others who are in need of pediatric specialty dental care. We charge for missed appointments and our requested cancellation policy is a 24 hour notice for all types of visits. A $35 Fee will be assessed per child for any missed or cancelled appointment without appropriate notice. Your cancellation must be made during regular office hours. You will be personally responsible for this charge. This charge will not be billed to, nor paid for, by your insurance company. As always, emergencies and unforeseen circumstances are taken into consideration. Initial: __________Informed Consent Information Name: ____________________________Required Treatment: I understand that my child requires the following treatment:□ Radiographs/X-rays □ Local Anesthetic Injection□ Filling/Restoration □ Prophylaxis □ Extraction □ Sealants □ Pulp Treatment □ Crowns □ Space Maintainer□ Mouth Prop □ FluorideRadiographs/X-rays – A radiographic image is formed by a controlled burst of X-ray radiation which penetrates oral structures at different levels allowing pictures of the teeth, bones, and surrounding soft tissues to screen for and help identify problems with the teeth, mouth, and jaw. X-ray pictures can show cavities, cancerous or benign masses, and hidden dental structures (such as wisdom teeth).__________Initial-7486658575040Phone: (909) 599-0283 | 00Phone: (909) 599-0283 | 1409699-714375Justin A. Shuffer, D.D.S.Specialist in Pediatric DentistryInfants – Children – Special Needs(Enter Company Name00Justin A. Shuffer, D.D.S.Specialist in Pediatric DentistryInfants – Children – Special Needs(Enter Company Name-933450-90932000-7486658575040Phone: (909) 599-0283 | 00Phone: (909) 599-0283 | -590550328930Local Anesthetic Injection: Injection of local anesthesia is needed to eliminate or minimize the potential discomfort associated with dental treatment. Local anesthetic injections may cause prolonged numbness of the face, cheek, lips, chin, tongue, and taste buds of the tongue. These areas can also experience altered feelings such as itching, tingling, or burning. In some cases the numbness, loss of taste, and altered feeling may be permanent and require special surgical procedures in an attempt to reverse the condition (rare occasion). For some children the temporary sensation of “numbness” may be fascinating and may suck, bite, pull, or chew the area. We strongly caution you to observe your child during this time and prevent them from harming themselves.__________ InitialFilling/Restoration: A restoration is usually placed in teeth that have small cavities. Following the removal of decay from the tooth, the tooth is “filled” with a filling material. The filling materials used is composite resin (white), or other materials that have been explained to you by the doctor. The benefit of restoring decayed teeth is to allow a tooth to be saved that would ultimately need to be removed due to pain and/or infection. The timely restoration of teeth by fillings is the least expensive way to maintain the dental arch and oral health. __________ InitialProphylaxis: Plaque is a mixture of food particles, saliva, and bacteria. If plaque is not removed from teeth it can lead to tooth decay (cavities) and irritation of the gum tissue making it tender, red, and bleed easily (gingivitis). If left untreated it may result in bad breath, yellow teeth, and bone loss (periodontitis). Dental cleanings can remove most stains; however, the success of the cleaning depends upon the quality of home care and oral hygiene. After the cleaning, fluoride treatment is done which strengthens the teeth and helps to prevent cavities. Your child should refrain from eating or drinking for at least 30 minutes to allow time for the fluoride to take its action. If excess fluoride is ingested, vomiting may occur.__________InitialExtraction: Following a tooth extraction there may be post-operative bleeding, swelling, discomfort, and infection, as well as stiff or sore jaw joints and limited opening of the mouth. There may be loss of feeling in the lips, tongue, and surrounding tissue that may be permanent and require special surgical procedures in an attempt to reverse the condition. During the extraction, adjacent teeth may be damaged. Some tooth fragments may stay in the gums which may work their way through the gum tissue during healing or may have to be removed if they become infected. Failure to extract a tooth that needs to be removed may cause infection of both the bone and soft tissues and in extreme cases, may be life threatening.__________ InitialSealants: Sealants are plastic coatings that are bonded to the chewing surfaces of posterior teeth to cover the grooves. Sealants make the surface of the tooth smooth and make it easier to clean effectively by brushing. Sealants help to prevent cavities but do not replace brushing and flossing. Sealants may need to be replaced or fixed periodically. The placement of sealants does not guarantee the teeth to be free of decay.__________ InitialPulp Treatment: Pulp treatment in primary teeth is similar to root canal treatment in adult teeth. The pulpal portion of the nerve is exposed, removed, and filled with medicament. Pulp treatment is not always successful and it is an attempt to save the primary tooth for as long as possible. Failure of a pulp treatment may result in infection, pain, and extraction of the tooth. Following pulp treatment, the tooth needs to be restored with a crown which will greatly minimize the risk of bacteria re-entering the tooth._________InitialCrown: Crowns are used to completely cover the tooth that had pulp treatment, or a tooth that has been weakened by decay. Crowns are also commonly used to restore a tooth that is cracked, discolored, or damaged. Crowns will improve the strength and appearance of the tooth. Crowns may be stainless steel (silver), resin (white), or other materials which the doctor has explained to you previously. The crown must be brushed and cleaned while brushing other teeth. Sticky foods such as caramels, taffy, and chewing gum can pull the crown off. If this should occur, do not lose the crown. Simply schedule a re-cementation of the crown._________ InitialSpace Maintainer: Space maintainers are needed with a primary tooth is lost prematurely due to decay, infections, or trauma. The space left needs to be maintained for the permanent tooth to erupt in the correct position. Space maintainers do not guarantee prevention of orthodontic treatment in the future. Plastic teeth may be used to cover the empty space (pedo-partial) at the discretion of the doctor. Space maintainers are cemented in the mouth by temporary cement and may become loose with time. Care must be taken to avoid loss or damage to the space maintainer. Sticky foods such as caramels, taffy, and chewing gum can pull the space maintainer off as well._________InitialMouth Prop: Mouth props are a hard plastic and sometimes metal instrument that helps to keep the mouth open during treatment. The use of the mouth prop prevents TMJ pain, discomfort, closing of the mouth during treatment, and accidental biting of objects. Mouth props are considered a restraint._________InitialFluoride Varnish: A highly concentrated form of fluoride applied to a tooth’s surface for anticavity treatment. May cause a temporary change in tooth color._________InitialEvery reasonable effort will be made to treat your child’s condition properly and safely, although it is not possible to guarantee results of treatment. By signing below you have read this document, understand the information about the proposed treatment, and have had all your questions fully answered.__________________________________________________ __________________Patient’s signatureChild’s nameDateDentist’s signature (Parent if patient is a minor)00Local Anesthetic Injection: Injection of local anesthesia is needed to eliminate or minimize the potential discomfort associated with dental treatment. Local anesthetic injections may cause prolonged numbness of the face, cheek, lips, chin, tongue, and taste buds of the tongue. These areas can also experience altered feelings such as itching, tingling, or burning. In some cases the numbness, loss of taste, and altered feeling may be permanent and require special surgical procedures in an attempt to reverse the condition (rare occasion). For some children the temporary sensation of “numbness” may be fascinating and may suck, bite, pull, or chew the area. We strongly caution you to observe your child during this time and prevent them from harming themselves.__________ InitialFilling/Restoration: A restoration is usually placed in teeth that have small cavities. Following the removal of decay from the tooth, the tooth is “filled” with a filling material. The filling materials used is composite resin (white), or other materials that have been explained to you by the doctor. The benefit of restoring decayed teeth is to allow a tooth to be saved that would ultimately need to be removed due to pain and/or infection. The timely restoration of teeth by fillings is the least expensive way to maintain the dental arch and oral health. __________ InitialProphylaxis: Plaque is a mixture of food particles, saliva, and bacteria. If plaque is not removed from teeth it can lead to tooth decay (cavities) and irritation of the gum tissue making it tender, red, and bleed easily (gingivitis). If left untreated it may result in bad breath, yellow teeth, and bone loss (periodontitis). Dental cleanings can remove most stains; however, the success of the cleaning depends upon the quality of home care and oral hygiene. After the cleaning, fluoride treatment is done which strengthens the teeth and helps to prevent cavities. Your child should refrain from eating or drinking for at least 30 minutes to allow time for the fluoride to take its action. If excess fluoride is ingested, vomiting may occur.__________InitialExtraction: Following a tooth extraction there may be post-operative bleeding, swelling, discomfort, and infection, as well as stiff or sore jaw joints and limited opening of the mouth. There may be loss of feeling in the lips, tongue, and surrounding tissue that may be permanent and require special surgical procedures in an attempt to reverse the condition. During the extraction, adjacent teeth may be damaged. Some tooth fragments may stay in the gums which may work their way through the gum tissue during healing or may have to be removed if they become infected. Failure to extract a tooth that needs to be removed may cause infection of both the bone and soft tissues and in extreme cases, may be life threatening.__________ InitialSealants: Sealants are plastic coatings that are bonded to the chewing surfaces of posterior teeth to cover the grooves. Sealants make the surface of the tooth smooth and make it easier to clean effectively by brushing. Sealants help to prevent cavities but do not replace brushing and flossing. Sealants may need to be replaced or fixed periodically. The placement of sealants does not guarantee the teeth to be free of decay.__________ InitialPulp Treatment: Pulp treatment in primary teeth is similar to root canal treatment in adult teeth. The pulpal portion of the nerve is exposed, removed, and filled with medicament. Pulp treatment is not always successful and it is an attempt to save the primary tooth for as long as possible. Failure of a pulp treatment may result in infection, pain, and extraction of the tooth. Following pulp treatment, the tooth needs to be restored with a crown which will greatly minimize the risk of bacteria re-entering the tooth._________InitialCrown: Crowns are used to completely cover the tooth that had pulp treatment, or a tooth that has been weakened by decay. Crowns are also commonly used to restore a tooth that is cracked, discolored, or damaged. Crowns will improve the strength and appearance of the tooth. Crowns may be stainless steel (silver), resin (white), or other materials which the doctor has explained to you previously. The crown must be brushed and cleaned while brushing other teeth. Sticky foods such as caramels, taffy, and chewing gum can pull the crown off. If this should occur, do not lose the crown. Simply schedule a re-cementation of the crown._________ InitialSpace Maintainer: Space maintainers are needed with a primary tooth is lost prematurely due to decay, infections, or trauma. The space left needs to be maintained for the permanent tooth to erupt in the correct position. Space maintainers do not guarantee prevention of orthodontic treatment in the future. Plastic teeth may be used to cover the empty space (pedo-partial) at the discretion of the doctor. Space maintainers are cemented in the mouth by temporary cement and may become loose with time. Care must be taken to avoid loss or damage to the space maintainer. Sticky foods such as caramels, taffy, and chewing gum can pull the space maintainer off as well._________InitialMouth Prop: Mouth props are a hard plastic and sometimes metal instrument that helps to keep the mouth open during treatment. The use of the mouth prop prevents TMJ pain, discomfort, closing of the mouth during treatment, and accidental biting of objects. Mouth props are considered a restraint._________InitialFluoride Varnish: A highly concentrated form of fluoride applied to a tooth’s surface for anticavity treatment. May cause a temporary change in tooth color._________InitialEvery reasonable effort will be made to treat your child’s condition properly and safely, although it is not possible to guarantee results of treatment. By signing below you have read this document, understand the information about the proposed treatment, and have had all your questions fully answered.__________________________________________________ __________________Patient’s signatureChild’s nameDateDentist’s signature (Parent if patient is a minor) ................
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